The current stage of research into recovery from serious mental illness Kuhn would describe as exploratory. Discoveries are random. Sometimes research is just ‘puzzling’. As people begin to integrate new information, research begins to establish itself as ‘normal’ and is part of a ‘coordinated and coherent view and is aimed at fine-tuning the ingredients of effective and accepted practice.’ (Knight 2000:8) This may take many years and is often an arduous process. Kuhn argues that there is no way to measure ‘progress’ in research. Real progress, the paradigm shifts are totally revolutionary. It usually takes a long time to effect a paradigm shift, often about 20 years. Different phenomena are seen as important to explain, making it impossible to objectively determine which one is better.

Topor (2000) examines the questioned paradox. If a chronic illness is expected to have a long life span, usually extending to the whole of a persons lifetime, recovery presents a challenge to the idea of chronicity in relation to schizophrenia and other serious mental disorders.

(Topor 2000)

In addition the term ‘chronically ill’ is attached to people whose illnesses have been long-term ill and long-stay patients in psychiatric hospitals. Being admitted to a hospital for psychiatric treatment was for a long time a simple criterion of chronicity. Problems occur where in recent years it has become possible to offer treatment, care and support through crisis resolution and home treatment teams in peoples natural communities that is as effective or better than hospitalisation. Definitions of chronicity remain attached to people with diagnoses of serious mental illness despite contrary evidence. With deinstitutionalisation and the closure of psychiatric hospitals, functional disability replaced chronic illness as a new criterion.

(Topor 2000)

Stigmatisation ensures that people whom psychiatry defines as chronic assume psychiatry’s definition of themselves thus creating a self fulfilling prophecy (Becker, H.S, 1963). The label of chronicity produces behaviour expected of chronically mentally ill people. Extreme environmental stressors may produce symptoms similar to those associated with mental illness. (Bettelheim, 1943) The chronic course of development in the condition is not inherent in the illness, but as a result of the lifestyle of the patient. Thus the biography becomes the biology.

Definitions of recovery within the literature and the consumer movement in the USA have broadened our understanding of the concept of recovery. At its simplest recovery can be defined as ‘a subjective experience of having regained control over one’s life.’ (Knight 2000) The achievements of those who have recovered embrace hope, empowerment and social connectedness

Schizophrenia is generally thought of as a chronic illness and it would therefore constitute a contradiction in terms to find a higher percentage of diagnosed people who have recovered. However, it has been clearly demonstrated that nearly 50-70% of people with a diagnosis of schizophrenia do recover but rather than simply a condition or state, recovery is more, it is:

(Strauss et al, 1987)

This ego is not restored to a state prior to the illness. In the active role of recovery the goal is not normalisation but:

(Anthony 1993)

With an emphasis on the subjectivity and psychological aspects of recovery, there is a danger that ‘the recovery process becomes as long-lived as chronicity.’ (Topor 2000:43) In aiming to provide a singular consumer definition of recovery from schizophrenia, which proved impossible, many people maintained that they considered themselves to be just ‘getting on with their lives’. (Tooth et al, 1997)

A service user-run business in Ohio was asked by a county mental health board to develop and implement an evaluation strategy to identify strengths and weaknesses in the county mental health system. These service users agreed that recovery was important, and generated a list of indicators, as well as ways professionals could be evaluated based on their impact on the recovery process - both positive and negative. These indicators, used in a pilot study in Ohio and in Maine with service users/survivors who had been admitted to the state institution at least once in the last seven years, were rated from most important to least important similarly by both groups. (Ralph, Lambric, & Steele, 1996; Ralph & Lambert, 1996) Ohio consumers rated the indicators in this order. The top four were the same top four rated by Maine consumers:

1. The ability to have hope
2. Trusting my own thoughts
3. Enjoying the environment
4. Feeling alert and alive
5. Increased self esteem
6. Knowing I have a tomorrow
7. Working with and relating to others
8. Increased spirituality
9. Having a job
10. Having the ability to work

Ridgeway (2001) analysed four early consumer recovery narratives (Lovejoy, 1984; Deegan, 1988; Leete, 1989; Unzicker, 1989) with a constant comparative method to find common themes. These themes are as follows:

1. Recovery is the reawakening of hope after despair
2. Recovery is breaking through denial and achieving understanding and acceptance
3. Recovery is moving from withdrawal to engagement and active participation in life
4. Recovery is active coping rather than passive adjustment
5. Recovery means no longer viewing oneself primarily as a mental patient and reclaiming a positive sense of self
6. Recovery is a journey from alienation to purpose
7. Recovery is a complex journey
8. Recovery is not accomplished alone – it involves support and partnership

In a review of recovery literature, Ralph (2000) identified four dimensions of recovery found in personal accounts. These are:

1. internal factors – those factors which are within the consumer, him/herself such as the awakening, insight, and determination it takes to recover;
2. self-managed care, an extension of the internal factors where consumers describe how they manage their own mental health and how they cope with the difficulties and barriers they face;
3. external factors which include interconnectedness with others, the supports provided by family, friends, and professionals, and having people who believe that they can cope with and recover from their mental illness; and
4. empowerment - a combination of internal and external factors – where the internal strength is combined with interconnectedness to provide the self-help, advocacy, and caring about what happens to ourselves and to others.

Tooth et al (1997), using Personal Construct Theory, examined recovery from schizophrenia from a consumer perspective. Longitudinal studies reviewed by Harding et al found a recovery or significant improvement rate of between 46 –68% of patients with schizophrenia (Harding et al 1987). Harding et al. have identified ways of separating out the residual effects of the disorder from the effects due to institutionalisation and other associated factors. McGory (1992) and Anthony (1993) also identify stigma, restricted choices, low self-expectation as factors contributing to chronicity in people with serious mental illness.

The Tooth et al (1997) study was designed to answer the following questions:-

1. What factors do consumers who identify themselves as recovered from schizophrenia consider the most important in their recovery?
2. What factors are reported most frequently?
3. What factors identified by the consumer group are similar to those identified in the outcome literature?
4. What factors identified by the consumer group are different to those identified in the outcome literature?
5. What do consumers define as recovery from schizophrenia?

Sixty participants were screened for a previous diagnosis of schizophrenia and were recruited through advertisements in local newspapers, through hospitals and consumer groups. Participants had to be self identified as recovered from schizophrenia. Fifty-seven men and women between the ages of 20 and 65 participated in the research. Using individual interviews and focus groups, participants were asked to identify what they considered the most important factors in their journey of recovery and what was helpful. The results were then systematically analysed. Eight categories were identified as follows:

1. The process of coming to terms with the disorder
2. Activities that were helpful
3. Environmental factors
4. Medication
5. Aspects of themselves that were helpful
6. Their network
7. Hospitalisation
8. Factors which did not facilitate recovery

The role of self was the most frequently reported theme, with the person’s determination to get better and manage their illness. Accepting the illness, identifying the crisis response and working with their ability to recover from the illness emerged as significant themes. Participants identified the importance of their social network and having friends who affirmed them and their experiences regardless of the illness. Taking action, facing problems and making choices are consistent with the notion of ‘internalised personal agency’ (Tomm in Tooth et al 1997:53) Over time in the struggle to recover, participants had externalised the problem of schizophrenia and moved beyond the limitations of the illness.

From responses in focus groups, 53% of participants named optimism and hope for recovery as significant. An equal number reported stigma as a negative aspect. Forty-nine percent identified the importance of spirituality in their recovery and a majority of participants identified a turning point in their journey of recovery.

Topor et al (1997) have made an in-depth study of ‘turning points’ on the journey of recovery from serious psychiatric illness. In selecting participants, only people are included who had an absence of admission into institutional care for a period of at least two years prior to the interview. Although at the time of the interview some participants were in touch with psychiatry, individuals were living a ‘normal life’ in society. Five persons were interviewed using a semi-structured interview guide, two women and three men between the ages of 32 and 51 years. Three had received a diagnosis of schizophrenia and two were diagnosed for personality disorders and affective psychosis. Two of the informants can be considered as recovered and three as socially recovered. Warner (1994) distinguishes between ‘social recovery’ and complete recovery. Social recovery implies that the former patient functions socially, but may still display some clinical signs of disorder such as hearing voices or having certain paranoid delusions. Recovery is regarded as a process (Deegan, 1988) and the former patient may still pay regular visits to psychiatric outpatient care for medication and/or therapy. Complete recovery implies that the former patient no longer displays any psychotic symptoms and has returned to the pre-illness level of functioning. (Warner, 1994) The analysis of the transcripts used grounded theory methodology. One theme in particular – ‘turning points’ emerged as dominant in the five narratives.

The results which emerge from this study go in some way to address the issue of recovery and chronicity. A ‘turning point’ and ‘the upward journey is not a straightforward linear process’ (Topor 1997:15) The breakdown and hitting bottom involves a descent to a place which ‘is characterized by feelings of impotence and the loss of a sense of identity’ (Topor 1997:8) The façade that had covered over the emptiness has collapsed. The qualities/characteristics of being in that place at rock bottom involve hopelessness and a gulf between the role and the individual, which can no longer be bridged.

(Cited in Topor et al, 1997:10)

At the ‘turning point’, a number of factors stand out as playing a crucial role. These may take the form of a fortuitous external event or a personal decision. Often the common agent of change is a ‘significant other’ or ‘good persons’. These may be friends, relatives, treatment staff, a particular medicine, a pet or God. These catalysing events come together in the form of an unexpected change in circumstances that force the individual to make a decision.